According to the philosopher Miranda Fricker, epistemic injustice occurs when someone is wronged “specifically in their capacity as a knower.” This comes in two forms, testimonial and hermeneutic injustice. Testimonial injustice happens when a person is assigned lower credibility due to prejudice and not based on any reasonable concerns about the testimony. The person belongs to a certain negatively stereotyped social group, and this creates a credibility deficit for members of that group. Hermeneutic injustice occurs when “the prejudicial flaws in shared interpretive resources prevent the subject from making sense of an experience which it is strongly in her interests to render intelligible.” (Fricker, 2007. Epistemic Injustice: Power and the Ethics of Knowing.)
Kious, Lewis, and Kim recently published an article in Psychological Medicine titled “Epistemic injustice and the psychiatrist” in which they argued:
“The concept of epistemic injustice does not add significantly to existing standards of good clinical practice, and that it could produce changes in practice that would be deleterious. Psychiatrists should resist calls for changes to clinical practice based on this type of criticism.”
I wrote a brief response to that, titled “Epistemic justice is an essential component of good psychiatric care,” which has now been published in Psychological Medicine. I’ll refer you to the original article and the correspondence to follow the discussion. Here are some excerpts from my letter:
“The central message I wish to convey is that the epistemic justice is an essential component of good psychiatric practice and there is no reason for the attitude of psychiatrists toward this framework to be one of antagonism. Medicine and psychiatry, practiced virtuously, are on the side of epistemic justice.”
“Epistemic justice is not something that is outside of good clinical care. Good clinical care is inclusive of our best ethical practices; just as good clinical care cannot be racist or sexist, good clinical care cannot be epistemically unjust. We cannot appeal to good clinical care to justify ignoring epistemic justice because epistemic justice clarifies a vital aspect of what good clinical care ought to be.”
“I believe we as psychiatric clinicians ought to be less defensive about the claim that ‘psychiatrists often perpetrate testimonial injustice’ and more concerned with the claim that psychiatrists can very well be, and at times are, guilty of testimonial injustice, just as psychiatrists can very well be, and at times are, guilty of sexism, racism, transphobia, homophobia, ageism, and sanism. The fact that we are capable of such forms of discrimination mandates that we exercise relevant vigilance.”
“‘Believe patients’ then, if it were to exist as an injunction, would similarly function as a corrective norm, a gesture of support for those individuals of marginalized classes (women, racial minorities, psychiatric patients, etc.) whose testimonies are treated in clinical settings – if not frequently, then often enough – as if they were inherently unreliable.”
Radoilska and Foreman also wrote a reply to Kious, et al. in Psychological Medicine: “Epistemic justice is both a legitimate and an integral goal of psychiatry: a reply to Kious, Lewis and Kim (2023).”
I’ll keep an eye out for a response by Kious, et al.
The debate above is primarily focused on testimonial justice. Last year, I wrote about Hermeneutic Justice and Medical Practice on my old blog. That piece was intended to be a brief and accessible introduction for a medical audience, so some readers may find it to be a useful complement to the current discussion.
“I am convinced that medicine on the whole has historically been on the side of hermeneutic justice. Medicine has created conceptual resources that have allowed individuals with various states of distress and disability to make sense of their experiences and access much-needed help. Furthermore, the medical framework has also saved vulnerable individuals from self-blame as well as societal blame by showing that the states in question are not under the ordinary control of the individual. Imagine, for instance, a society in which the medical concept of addiction does not exist, and the only way addiction can be understood is in moral or religious terms. Fricker herself gives the example of postpartum depression and refers to the story of a woman from the history of US women’s liberation movement who realized after a group discussion that she had been blaming herself and her husband had been blaming her for failings which were in fact a product of postpartum depression, a psychiatric condition, and realized that it wasn’t her personal deficiency (2).
The situation, however, is not that simple. The medical framework has acquired tremendous social power over the last half-century or so. This power also comes with a danger of displacing and suppressing non-medical narratives that may be necessary for self-understanding and without which individuals may be left “troubled, confused, and isolated.” (1) Consider, for instance, an individual with autism who has no access to the notion of “neurodiversity” and the only way she can think of herself is in terms of abnormality or deficit. Or consider an individual who has been told that his depression is a meaningless product of faulty neurochemistry and has no access to conceptual resources to contextualize his distress and understand his depression as meaning-laden.
Such instances of epistemic injustice are not inherent to the medical framework. They arise when medical explanations are privileged to such an extent that other modes of understanding become inaccessible, or when medical perspectives are incorrectly assumed to be complete and exclusive descriptions of the reality of the phenomena. Recognizing this as one source of the problem also suggest a possible solution: epistemic humility.”
This is not directly about epistemic justice, but yesterday I came across a wonderful passage written by Niall Boyce, then editor of the Lancet Psychiatry, from a 2014 editorial, “Duel Diagnosis,” which I think is worth sharing:
“Do not dismiss biological data as an irrelevant folly, nor philosophical and sociological analysis as a form of obscurantism. Take some time to consider your opponent’s intellectual discipline, and how his or her work might be criticized on its own terms. This might be a long, difficult, and tedious process, but it is what patients, and the public, deserve. The final point is to ensure that those whose voices are not listened to enough are given the space and opportunity to be heard. Their numbers include individuals such as mental health nurses and social workers, who provide a large amount of care but who are given little time compared with psychologists and psychiatrists. Most important, the voices of patients must be “airtime” respected in all their diversity.”
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This is an important and interesting discussion, Awais--so thank you! Having read the Kious et al piece and your rejoinder, I have just a few observations and concerns.
1. I find the term "epistemic injustice" problematic from the standpoint of conceptual categories. The term seems to conflate two separate branches of philosophical discourse: epistemology and ethics. The first has to do with what we know or can validly claim to know; the second, with what is "right", "just" or "moral." There are, of course, connections and "bridges" between these two categories--for example, can we ever "know" whether or not there is an objective standard of moral behavior?--but I am still concerned that the term "epistemic injustice" entails a category mistake of the sort Gilbert Ryle
warned against. To put it in crude terms: is not the term "epistemic injustice" a bit like the term
"geometrical dishonesty"? Triangles are neither honest nor dishonest. Knowledge claims are neither just nor unjust--though they may be unfounded.
2. It seems to me that the debate is less about "epistemic injustice" than about a careful, fair-minded, and respectful approach to what patients tell us. I suspect few psychiatrists would argue against that stance. But being careful, fair-minded and respectful does not compel us, reflexively or credulously, to "believe patients."
3. As you rightly point out, Awais, "Beliefs should be attributed the credence that is merited." I would add, "No more and no less." And what is "merited" depends crucially on the psychiatric context of the patient's beliefs, and upon the psychiatric diagnosis. If a patient is diagnosed with delirium and insists that a vicious lion is present in the emergency room, that belief does not merit the "credence" that we would attach to the same patient's saying, "I feel sick to my stomach", or "The nurse was rude to me."
There is no prima facie reason to diminish the credibility of these two claims, merely because the patient is delirious.
3. A psychiatrist who insists (against the best available evidence) that a patient's depression is nothing more than a meaningless chemical imbalance is simply being an incompetent and ignorant psychiatrist. We know on the basis of decades of research that depression has manifold
"meanings" to our patients, relating to self-esteem, self-blame, guilt, the opinions of significant others, etc. I do not see any need to invoke the term "epistemic injustice" to characterize the hypothetical psychiatrist's narrow-minded claim. And I would add that very few psychiatrists, in my forty years of experience, would hold to such a simplistic view of depression.
4. Notwithstanding my concerns with the term "epistemic injustice", it is the case that psychiatric patients are often dismissed in utterly inappropriate ways. One of my teachers in residency used to say, for example, that "Hysteria is the last diagnosis a patient will ever receive"--because any complaint can be dismissed as "hysterical." So we need to be very careful in avoiding this sort of prejudice, and being scrupulous in our diagnostic efforts.
Thanks again for the interesting discussion!
Ronald W. Pies MD